Do We Really Need 30,000 More Primary Care Doctors?

Sarah Kliff thinks so, reporting in the Washington Post that the health care expansion envisioned in the Affordable Care Act will require an expansion of doctor supply as well. She outlines quite well the economic statistics involved and the currently-overwhelming incentives for young physicians to go into lucrative specialities. But there’s a 900-pound gorilla stomping all over the article.

Why exactly do we need primary medical care to be provided by doctors? Advanced practice nurses such as nurse practitioners often provide better care at a fraction of the cost. For many years I had a nurse practitioner as my primary care provider and still use one currently in most situations. As a friend of mine recently told me, “Nurses are patient-centric; doctors are disease-centric.” Well, when I become a disease, then I’ll see a doctor for my primary care. Note that I am not talking about any and all nurses, but rather only those who have advanced certifications — which are far less expensive to get than medical degrees.

What does the Post have to say about this possibility? Well, nothing at all. Not a single nurse is quoted in the piece. It simply assumes that we need doctors to provide primary care, and quotes the head of the American Academy of Family Physicians – which appears to have many of the characteristics of a trade group as well as a scientific and professional society.

Primary care doctors are great. It’s terrible that the incentives for young doctors to enter into specialities are so skewed. But while we are busy panicking and calling the fire department to put out a blaze, we might also want to think about picking up the hose next to us. The fact that we can’t even talk about this possibility suggests either a terrible lack of vision or physicians’ ability to artificially restrict the discussion. Or both.

Comments

Oh yes — no question that there are gender dynamics here that, if looked at closely, would not be particularly pretty. Nursing has less social prestige than it should because it is viewed as “women’s work.” That said, new primary care physicians are disproportionately women because it is a lower-paying specialty and there is strong bias in other specialties, like surgery.

True and true. But the gender barriers these days are corroding from both ends–more female docs and more male nurses. Of course, there is also a social class divide–parental resources help in becoming a physician much more than for nursing.

I’d vote for “terrible lack of vision”, which seems to shape so many issues, and afflict our politics broadly.

One source of that “terrible lack of vision” is that we’ve become a rentier’s economy and state, with not very nice rentiers in charge. Ideas and organization have to be funded, and the only source of such discretionary incomes are economic rents, which are concentrated in the hands of elites of narrow vision and interest — as exemplified in the earnest policy entrepreneurship of the American Academy of Family Physicians.

Intellectually, it doesn’t help that economists have spent 100 years studiously ignoring the rise of bureaucracy, in favor of spinning out myths of the Market. In health care, the advance of medical knowledge has been pushing hard on the limits of individual human cognition for decades. I would question not just whether we can afford doctors as internists in general practice, but whether anyone can actually competently carry out that role. Medical care as a craft is simply obsolete, and, to make good use of the medical knowledge, medicines and devices available, we have to organize delivery of health care services in rule-driven hierarchies. That’s not just simply substitution of nurse practitioners for doctors on the front-lines, though that might be part of the overall plan. Eliminating the pathologies of for-profit insurance, and perhaps fee-for-service as well, in favor of some other funding/financing model is also required.

Thirty years ago the Office of Technology Assessment did a study that found that NP’s could provide 80% of primary care needs at 1/3rd the cost of physician care. p://www.aanp.org/NR/rdonlyres/197C9C42-4BC1-42A5-911E-85FA759B0308/0/CostEffectiveness4pages.pdf

This didn’t happen because doctors didn’t want it to happen. Insurance companies would have loved it, but they are not as powerful as doctors.

The real reason for the shortage of primary care providers is the doctors’ lobby.

Well, the nurse practitioner who saw my kids at Minute Clinic charged a hundred bucks apiece plus 25 more for the strep tests. That’s not too far off what the pediatrician would have charged – though it was lots faster and no appointment necessary.

Given that the US also has a shortage of nurses, it’s not clear to me exactly how this solves the problem…

There are certainly social issues at play here. The medical profession seems dominated by psychopaths who feel that hazing doctors (as interns) is appropriate, and who continue that behavior throughout their career, only now directed at nurses — leading to 20% of trained US nurses choosing not to work in nursing as soon as they can escape.
I have no problems with giving nurses more of a role in primary care, but I suspect we’re better off all round asking why it is that so many of them felt it worth leaving the career they trained for — and I suspect the answer is larger than “I wanted to treat patients in the role of a doctor”.

Hazing interns is an ancient rite of passage: the belief is, “I had to do it, and so those following should do it too.” It’s unfortunate, because it is very well documented that a resident in the 24th hour of a 32+ hour provides care on about the same level as a bowl of oatmeal. It leads to medical errors, and iatrogenic injuries.

The justification is that residents need to see the full disease process to become effective doctors, and in order to see the “full process” they have to be on campus for an inordinate amount of time. This is changing, but only slowly.

There has been a move in the nursing world to hold advance practice nurses in training longer, and instead of giving them a M.Nurs. they receive a D.N.P. (Doctor of Nursing Practice, or some such). Physicians are much less than enamored with this idea. What a surprise, no?

And physicians wonder why people believe M.D. stands either for Medical Diety or Me Doctor (You not!). There is no question that we need more health professionals in primary practice, but the financial realities are such that it is very unlikely that those primary practitioners will be physicians.

Dennis obviously has no idea what he is talking about go to an NP And she will merely refer you to 10 sub specialists for every single problem ,it takes an MD WITH YEARS OF EDUCATION AND EXPERIENCE. To figure out not someone going through a quick education system

Before NP’s there were Physician Assistants. This program was started by the Army to help provide healthcare to the troops because of the shortage of docs in a volunteer military. My dad was in the first class of PA’s graduated by the Army. After retiring from the military, he went to work for Kaiser Permanente, and then for private physician groups after Kaiser. I’ve seen NPs and PAs and both have been great. Especially for typical female problems and typical pediatric problems.

My one experience with a nurse as a primary medical care provider was awful. To an extent I’ve never encountered with a doctor, this “Physician’s Assistant – Certified”, as she was called under DC law at the time, seemed to consider all of my medical needs to be moral failings. On the other hand, every experience I’ve had with a nurse providing nursing services in a hospital has filled me with admiration for the work of nurses. As I remarked to a nurse who tended me when I was hospitalized a couple of years ago, “every time I receive care from a nurse, my opinion of your profession goes up.” A limited set of data points, obviously, but in my experience I’d rather be nursed by a nurse and doctored by a doctor.

PA’s (Physican’s Assistants) are not nurses. They train in Physician Assistant programs that are not part of nursing schools and they don’t get any nursing training at all. NP’s (nurse practitioners) are nurses with the RN license who go on to further training in diagnosis and treatment. My own experience with PA’s has not been very good. I had one tell me, after I’d smashed my foot into a wall (you don’t want to know), that my pain might be a symptom of gout. But my experience with NP’s has been that they’re intelligent, knowledgeable, perceptive, and caring.

Physician assistants and nurse practitioners are known as “physician extenders.” Like physicians, some are better than others, but they do have limitations. If I see the nurse practitioner, I can get prescriptions, but I can’t get treatments. So, if I see the nurse practitioner, and she decides I need a cortisone injection for my bursitis, I have to come back a second time to see the physician.

Physicians also have to supervise them, taking away their time from the patients. To malpractice lawyers, they are known as “low hanging fruit,” because their supervision is often spotty as a result. They are easy targets for malpractice.